Towards a framework for telenurses’ decision making: the decision ladder

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Towards a Framework for Telenurses’ Decision Making: The Decision Ladder by

Danica S. Tuden RN, Langara College, 1988 BSN, University of Victoria, 2009 A Thesis Submitted in Partial Fulfillment

of the Requirements for the Degree of MASTER OF SCIENCE

in the School of Health Information Science

 Danica S. Tuden, 2016 University of Victoria

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Supervisory Committee

Towards a Framework for Telenurses’ Decision Making: The Decision Ladder by

Danica S. Tuden RN, Langara College, 1988 BSN, University of Victoria, 2009

Supervisory Committee

Dr. Elizabeth Borycki, School of Health Information Science Supervisor

Dr. Andre Kushniruk, School of Health Information Science Departmental Member

Mary Alyse Capron, MN, School of Health Information Science Departmental Member

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Abstract

Supervisory Committee

Dr. Elizabeth Borycki, School of Health Information Science Supervisor

Dr. Andre Kushniruk, School of Health Information Science Departmental Member

Mary Alyse Capron, MN, School of Health Information Science Departmental Member

Telenursing is a highly specialized area of nursing practice that has evolved in

response to the advent of new technologies within the delivery of health care. Telenursing has been defined as “the use of communications and information technology [ICT’s] to deliver health and health care services and information over large and small distances (CRNBC, 2016). Telenurses use health information systems (HIS) in the form of a Clinical Decision Support System (CDSS) to assist callers with their health related concerns on a 24/7 basis. As decision making is an integral part of telenurse practice, particularly because they are using a CDSS while assessing the caller over the phone, it was important to understand the factors that influence the decision making process so as to better support telenurse practice in terms of education as well as other supports. This thesis identified those factors and used Rasmussen’s Decision Ladder as a model in order to provide a framework for telenursing. It was found that there were several factors identified that influenced how telenurses made decisions while using a CDSS. Additionally, the decision ladder was validated as a framework to describe telenurse practice.

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List of Tables

Table 1 Mapping of Decision Ladder Concepts to Codes for Analyzing Telenursing

Decision Processes. ... 35

Table 2 Potential Manifestations of the Various Behaviours as Related to Telenursing. . 36

Table 3 Demographic Characteristic of Telenurse Participants. ... 40

Table 4 Post Call Simulation Interview Responses. ... 75

Table 5 Data Elements with Potential Relevance to Shortcuts. ... 76

Table 6 Decision Ladder Steps and Correlation within Telenurse Practice. ... 87

Table 7 Incidence of Rasmussen’s Decision Ladder Steps within Telenursing. ... 104

Table 8 Factors Influencing Telenurse Decision Making. ... 111

Table 9 Rasmussen's Decision Ladder Steps Mapped to Telenurse Practice Explicitly 100% of the Time... 122

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List of Figures

Figure 1: Rasmussen's Decision Ladder in its Original Form (Rasmussen, 1994). ... 25 Figure 2: Telenurse Workstation Design for Clinical Simulation. ... 31 Figure 3: Rasmussen’s Decision Ladder as Compared to an Adaptation within Telenurse Practice. ... 83 Figure 4: Rasmussen’s Decision Ladder as Compared to an Adaptation within Telenurse Practice: Short Cut in Heart Attack Scenario. ... 118 Figure 5: Rasmussen’s Decision Ladder as Compared to an Adaptation within Telenurse Practice: Breast Feeding Mom and Baby... 121

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Acknowledgments

I would like to thank my previous employer for allowing me to use the Telenurse call centre as the environment to which I performed this research. In addition, I would like to thank the telenurses who volunteered to act as my research participants.

A special thanks to Lee Ashbourne, Alyse Capron, and Peter Quick, who not only supported my decision to pursue this degree, but in fact were the key mentors in suggesting this as a possibility. In addition, my long time mentor and friend, Kelly Henderson, was integral in supporting my work.

Above all, I would like to thank Dr. Elizabeth Borycki and Dr. Andre Kushniruk at the School of Health Information Science at the University of Victoria. Their support and guidance throughout this journey were integral in facilitating the completion of this research.

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Dedication

I would like to thank my wonderful husband, Vincent Johnstone, for supporting me throughout this educational journey. Also, my mother, who shares my name, Danica Tuden, has always been an inspiration to me. She encouraged me to continue pursuing my education when she was terminally ill with leukemia. This degree will be named in her memory as she passed away December 3, 2010.

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CHAPTER 1: INTRODUCTION

Registered nurses (RN’s) have provided advice over the telephone informally for

many years in areas including emergency rooms and public health units (Goodwin, 2007). There were no standardized protocols available to these nurses as there are today in the form of computerized decision support systems (CDSS). Consequently, a nurse relied solely on his or her experience and clinical judgment to offer health advice. As health care has become more costly and increasingly difficult to access, telehealth nursing was identified as a strategy in an attempt to alleviate these problems. In fact, the World Health Organization (WHO) considered telehealth so effective in managing these issues that they published a brief to recommend that policy makers need to invest in telehealth as a solution to integrate health care (Stroetmann et al, 2010). Therefore, an investment in implementing telehealth in terms of cost effectiveness would assist in ensuring that consumers use health care resources appropriately. It is clear that an emergency room (ER) visit is several times more costly than a trip to a general

practitioner (GP); however, it is also evident that GP’s are becoming increasingly more difficult to access. A simple telephone call to a nurse in a telehealth call centre can help in supporting a patient so they may get to the right place safely at the right time. In fact, a systematic review of Canadian telephone triage services indicated that 50 % of calls were manageable with home treatment alone (Stacey et al, 2003). The investment of telenurse call centres by government is clearly an economically sound decision.

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1.1 Telehealth Nursing

According to the College of Registered Nurses of British Columbia (CRNBC), telehealth is defined as “the use of communications and information technology [ICT’s] to deliver health and health care services and information over large and small distances” (CRNBC, 2016). In particular, telenursing is specific to registered nurses using ICT’s in order to provide health care. Telenursing is a highly specialized area of nursing practice that has evolved in response to the advent of new technologies within the delivery of health care. This unique field of nursing has been utilized as such an option to many countries world-wide such as the United Kingdom (U.K.), the United States (U.S.) and Canada. The concept of telenursing has been employed in areas such as chronic disease management, call centres and palliative care. General symptom triage and health education advice is often provided in a telenurse call centre, which is typically

operational on a 24/7 basis. Within this setting, telenurses assess a caller’s symptoms and use a CDSS in order to determine a recommendation on how and when to seek care. Telehealth call centres typically employ telenurses to provide symptom triage and health education to callers. It is important to note that telenurses come from diverse

backgrounds such as various units within acute care hospitals as well as community settings. As most telenurse call centres provide generalized health care, telenurses use a CDSS in order to support and complement their workflow. For example, a telenurse with a background in pediatric oncology would not be as familiar with a caller who presented with symptoms that were mental health related, and thus, the use of this kind of health

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information system (HIS) is very important in the goal towards managing a larger population of callers.

Further to the discussion related to cost effectiveness, there have been some arguments on the rationale as to why to employ a RN as a call taker in this type of setting in light of the fact that would certainly be more costly than a non-clinical individual. The fact that CDSS are utilized to support staff in managing calls might lead one to believe that asking some simple questions word for word would be well suited to non-clinical individual. In reality, any lay person can ask “yes” and “no” questions prescriptively within an

algorithmic protocol, but it is the RN who has the knowledge and expertise in providing

individualized and holistic care who would be most appropriate in this role. The telenurse

uses the CDSS to accompany his or her knowledge and experience and consequently, would not be bound to use it prescriptively. In fact, the literature shows that a typical telenurse has an average of 28.7 years of nursing experience (Greenberg, 2009). A CDSS is only a tool; and nurses have the tacit knowledge that no software can capture every situation; in essence, no two patients are alike. This knowledge, coupled with the fact that there is no face to face physical assessment to rely on, requires a telenurse to possess excellent communication skills as well as expertise in decision making.

1.2 Decision Making

Decision making is a complex cognitive process whereby individuals use their knowledge and experience to form actions. Kushniruk (2001) identified that telephone triage is a domain where high-performance decision making is closely associated to the overarching methods in interpreting the urgency of each unique situation. In fact,

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situations that present with a high degree of task intricacy, heuristic approaches, or, ‘rules of thumb’ may be employed (Kushniruk & Patel, 2004). Kushniruk (2001) further

reported that the actual ‘decision event’ is preceded by a complex process where the individual weighs various alternatives in how to proceed. As health care is concerned with ensuring patients receive safe and high quality care, it is evident that decision making needs to be thoughtful and meaningful. HIS can certainly facilitate the goal of appropriate decision making in terms of the utility of CDSS, but the user ultimately has the power and professional responsibility in making the final decision. For example, RN’s use particular software as their main CDSS to assist callers in how, when and where they need to access health care; however, there is some uncertainty as to the degree of rigidity telenurses employ in using these systems. Also important to note is that the patients calling for assistance may experience symptoms ranging from that of a simple hangnail to something more urgent and life threatening, such as heart attack. In the latter circumstance, it is clearly necessary to ensure that a patient is attended to as quickly as possible to preserve life and minimize morbidity; therefore, the telenurse may need to revise his or her decision making in using the CDSS. A model that is flexible to this kind of health care delivery is absolutely essential in order to provide some guidance and structure to telenurses.

As telehealth is a relatively new means to providing health care, it is important to understand, and thus, support the role that critical thinking plays in how telenurses make decisions while using HIS. Unlike traditional nursing care, telenurses are limited in terms of the accuracy and quality of information they receive from callers as they cannot perform a physical assessment. In addition, the information that a caller reports must be

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analyzed and interpreted while simultaneously researching and documenting the

appropriate health information. Schleyer and Beaudry (2009) explained this as a process of transforming data into wisdom whereby the interpretation and integration of the data results in individualized patient outcomes. Essentially, nurses are able to fine tune their use of the nursing process with the application of critical thinking skills they have acquired and developed from their years of experience. This experience provides a telenurse with a general foundation of knowledge that is essential in decision making towards the management of these patient encounters.

1.3 Clinical Decision Support Systems (CDSS)

Musen, Shahar and Shortliffe (2006) defined a CDSS as “any computer program designed to help healthcare professionals to make clinical decisions” (p. 700). They further identified three categories in the requirements for excellent decision making, which include data accuracy, appropriate knowledge, as well as appropriate application of problem solving skills (Musen et al, 2006). Essentially, the information in the CDSS needs to be evidence-based, which means in order to maintain accuracy and currency, regular reviews and updates need to occur. In addition, the information needs to be comprehensive enough to be able to address a situation or scenario yet balanced with an understanding that the end user should not be overwhelmed with an abundance of information. Finally, the end user needs to have working knowledge of the information within the CDSS to be able to make sound decisions. In terms of telenurses making decisions using the CDSS, this would involve the use of problem-solving skills, or as it is more often termed under the domain of the nursing profession, critical thinking. All of

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these components collaboratively aim to streamline health care delivery with the overarching objective of patient safety (Morris, 2002).

CDSS are employed for various purposes related to health care ranging from alert reminders, such as in allergy alerts, to algorithmic protocols which are used to provide recommendations for health care. One particular application uses algorithmic protocols as its main focus in decision support. Its vendor is a non-for profit organization that

develops health content and health education solutions including CDSS’s to such telehealth call centres. In addition, it provides health content applications for consumer health portals, hospitals and health care management companies. This vendor is

specifically used in one major Canadian telenurse call centre. In this organization, telehealth nurses use this application as their CDSS in order to provide symptom triage and health education to callers. A similar application, the Knowledge Base (KB), is used as the web-based information application for the public consumer. Depending on the organizational policy, research shows that CDSS’s can be utilized in various ways especially when RN’s or telenurses, are employed (i.e. more prescriptively or with more flexibility). Furthermore, individual telenurses may use these tools quite differently depending on their education and years of nursing practice. This research will serve to explore the various ways in which telenurses use CDSS as well as provide some groundwork in understanding critical thinking within decision making.

1.4 Decision Ladder

Several decision making models are available that range on a continuum from methods which are purely analytical to those that are more naturalistic. One tool in

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particular that has some interesting naturalistic aspects of decision making is based on Rasmussen’s work in terms of the ‘decision ladder’ (1993). This model is concerned with the control task phase of cognitive work analysis in health care proposed by Rasmussen and Peterson (1994). Cognitive work analysis is a method which considers the entire work system, including the individual, organizational, task-related, environmental and technological factors (Rogers, Patterson & Render, 2011). The decision ladder was developed by Jens Rasmussen and Annelise Mark Petersen, and later advanced by

Vicente (Rogers et al, 2011). The goal of performing a cognitive work analysis is to offer some awareness into those work tasks that pose challenges and barriers in cognitive processes and therefore, has the potential to propose some insight into systems, such as in the case of CDSS (Rogers et al, 2011). Cognitive work analysis is concerned with five phases, the second of which includes a control task analysis. As telenursing is concerned with decision making, the focus will lie within this phase and as such, will consider the decision ladder as a potential framework. Furthermore, the fact that this model has the capability to provide the opportunity for heuristic shortcuts may have some interesting implications for telenursing in terms of the degree of a caller’s symptom urgency and/or complexities.

1.5 Statement of the Problem

It is clear that the movement toward telenursing as a health care platform for service delivery is becoming more accepted and evident throughout many locations.

Furthermore, there are more opportunities for business cases within telehealth organizations whereby nurses will begin to support clientele with more complex and

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sensitive health care needs. The anticipated expansion of telenurses supporting health care in new and unprecedented methods requires a model or framework to assist decision making, especially while using HIS. Because there is little research on models or

frameworks to guide and support this skill within the nursing profession, let alone within telenursing, may pose some challenges in further in supporting and enhancing telenurse practice. Certainly, in B.C., the CRNBC provides a practice standard for RN’s in telehealth (CRNBC, 2016).

Loiselle and Profett-McGrath (2007) addressed the point that nursing theories borrow models from other disciplines such as psychology and in fact, this has even been

considered controversial because there is advocacy in developing unique nursing

theories. It is not clear as to why this is the case, essentially because of the reality that all humans make decisions – nurses are no different. Therefore, testing a model, such as that of Rasmussen’s in a telehealth setting is not an unrealistic task to embark upon. In reality, there are other models that have been borrowed and tested from other disciplines in terms of decision making. To illustrate this, an example of this was evident in terms of Bond and Cooper’s (2006) research on Klein’s work in regards to the Recognition Primed Model for Decision Making (RPD). Klein, who is a psychologist, developed this model when studying decision making in real world settings such as in the work of urban fireground commanders. This example will be discussed further as it is clear that models can be successfully applied to other disciplines.

As previously mentioned, there are few studies that have discussed decision making models within telenursing. One model in particular proposed by Greenberg (2009) illustrated a process of telephone nursing. This model addressed Schleyer and Beaudry’s

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concept of the translation of data into a context that is individualized to a caller (2009). This model certainly provides a platform for nursing in terms of the various phases of decision making. Also, Greenberg (2009) does clarify that these phases are iterative and cyclical and may in fact move more quickly in situations where a caller may have more urgent symptoms. It may not; however be as explicit in delineating the data processing and the resultant states of knowledge as are clearly demonstrated in Rasmussen’s decision ladder. Furthermore, the phases in Greenberg’s (2009) model may not be as obvious in demonstrating the short-cuts supplied in Rasmussen’s decision ladder. Again, we have many models, theories and frameworks for nursing in general, so testing another model, especially from a different domain would not be an unordinary practice.

1.6 Significance and Purpose of the Study

As telenursing is a relatively new process of health care delivery, it is important to ensure that it is provided to patients in a manner that is consistent with best practice in mind. There are several models and frameworks that provide a foundational support to nursing practice in a broad sense, but little research speaks to telenursing specifically in terms of critical thinking within decision making – especially as telenurses use HIS to assist patient callers. Understanding and thus, enhancing decision making skills through organizational supports and educational opportunities are vital to ensuring a future towards a high quality of telehealth nursing. Therefore, research in this area, including an assessment of other existing models or frameworks, such as that of Rasmussen’s decision ladder will serve to facilitate this journey.

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1.7 Research Objectives

The objectives of this research are to:

 Understand the cognitive processes of telenurses’ decision making with the use of HIS; specifically CDSS

 Identify the factors that influence how telenurses use CDSS

 Explore the use of heuristics or “short-cuts” by telenurses while using CDSS

1.8 Research Questions

1. How do telenurses make decisions while using CDSS?

2. What factors influence how telenurses make decisions while using CDSS? 3. What aspects dictate how and when nurses employ shortcuts/heuristics while

using a CDSS?

4. How well does the data map to Rasmussen’s decision ladder and cognitive levels of decision making?

5. Do telenurses perceive the CDSS as supporting their decision making?

1.9 Summary

Telehealth nursing is an emerging platform to health care service delivery and as such, it requires the attention of stakeholders and policy makers to ensure that it is involved in a process of quality improvement. This includes continual organizational support and the provision of ongoing education. Before this can come to fruition; however, we need to understand the basic, yet complex nature of decision making. Models and frameworks

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have the potential to provide us with this understanding and thus, adding an existing model into a new domain may be of significance to the contribution of the ultimate goal: safe and quality patient outcomes in telenurse practice.

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CHAPTER 2: LITERATATURE REVIEW

2.1 Introduction

Telehealth nursing or, ‘telenursing’ is an evolving area of health care service delivery. As critical thinking is an essential element in formulating decisions, it is important to understand, and thus, support the role that critical thinking plays especially when HIS such as CDSS are utilized. In conducting a review of the literature, it was noted there was an abundance of information available about critical thinking and decision making in general nursing practice. In terms of telehealth, however, there were only a limited number of studies available. The publications that were found focused on a telenurse’s experience of using a CDSS as well as some usability issues. The information gleaned from these studies identified some common themes within the context of decision making which will be explored. Based on the fact, however, that the research is somewhat thin in these important telenurse skills, the results of the review of this literature suggests the need for more research to be pursued in order to support and enhance quality patient outcomes as well as the appropriate use of health care resources. In addition, the research will require some focused attention on models and frameworks for guiding telenurse practice.

2.2 Telehealth Nursing (Telenursing)

As previously mentioned, telehealth nursing is a very specialized form of health care service delivery. The Canadian Nurses Association (CNA, 2007) developed and issued a position statement on the role of the nurse in telehealth in order to highlight some of the

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professional and practice standards in a telehealth context. For example, this document explains nurse-client relationships, privacy and confidentiality as well as the practice environment in terms of telehealth practice. Essentially, the CNA (2007) defines nursing practice in telehealth (i.e. telenursing) as “all client-centered forms of nursing practice and the provision of information and education for health care professionals occurring through, or facilitated by, the use of telecommunications or electronic means” (p. 1). There are many avenues for telenurse positions, such as in telemonitoring of patients in chronic disease management. For the purposes of this work, the author will focus on a more generalized approach to providing telephone symptom triage and health education such as in a telenurse call centre setting. Arnaert and MacFarlane (2011) defined tele-triage as the “process of assessing the priority of urgency of patient’s symptoms by telephone” (p. 35). Telenurse call centres are typically a 24 hour per day, 7 days a week operation (in order to meet the needs of patients seeking health advice). The Emergency Room (ER) is generally the only option during the night so it would be prudent to have service available when resources are minimal, as well as more costly.

2.3 Telenursing and the Cognitive Process of Decision Making

Kushniruk (2001) reported that psychological research within decision making

primarily concentrated on a term called the “decision event” in which the decision maker considers the options and selects a plan of action. Additionally, he reported that health care professionals make decisions under unique conditions where there is often

uncertainty as well as a variety of potential interpretations on how patients present (2001). In terms of telenursing, these descriptions of the complexities in health care are

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evident. Telenurses care for callers over the phone while ubiquitously using a CDSS and because there is no way to know what a caller is presenting with on the other end of the line, the complexities surrounding this type of health care delivery has its own decision making challenges. For example, the data that a telenurse collects from a caller must be carefully analyzed as there is no face to face physical assessment. Kushniruk (2001) also identified telephone triage as an area whereby high-performance decision making is associated with ruling out emergent symptoms, such as in the case of a caller with a potential heart attack. Certainly a telenurse is able to rely on the use of a CDSS, but because callers are not always able to clearly articulate their situation because of factors such as language barriers or health literacy issues, the telenurse must rely upon

knowledge, expertise and critical thinking in making sound clinical decisions. The process of decision making can be varied within the domain of telenursing depending on factors that are discussed in the next sections. Kushniruk (2001) described Hammond’s work within decision making as identified along a cognitive continuum, which ranges between intuition and analysis. As one of the goals is in ensuring that callers receive the appropriate level of care, it is important to understand and acknowledge the factors that influence where telenurses make decisions along this continuum. This understanding will serve to provide a potential basis in supporting and further educating telenurses in

offering an optimal degree of care. Furthermore, it may offer some insight into the system development life cycle (SDLC) of CDSS (Kushniruk, 2001).

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2.4 Telenursing and Decision Making: Influences of Stress and Fatigue

Berkow, Virkstis and Stewart (2011) mentioned three factors which have contributed to a shift in patient population in an acute care hospital: (1) a decrease in patient’s length of stay, (2) an increased patient acuity and complexity, and (3) a growing number of protocols. These issues can influence a call centre in terms of the types and numbers of calls telenurses receive. For example, patients are being discharged more quickly than ever and have the potential to develop complications at home where they would have been previously monitored by nurses. Furthermore, patients do not always fully absorb the limited discharge teaching they were offered in hospital because of factors such as pain and anxiety and as such, may also contribute to incoming calls. Employed recently as a telenurse, the researcher has experienced these calls, which do come in at any hour of the day. An example of this is where a patient calls at night for advice on potential signs of a postoperative wound infection. It is for these reasons that a 24/7 operation is

appropriate as it contributes to cost effectiveness.

As previously noted, a telenurse call centre is available for patients to obtain health care advice around the clock. It is evident as to the reasons such a setting is useful in terms of cost effectiveness and efficiency. However, it is important to keep in mind that telenurses work all shifts and therefore it is expected that there they will experience a degree of stress and fatigue. In addition, stress and fatigue can increase for a telenurse when there are many patients waiting to receive care. Although a telenurse cares for one caller at a time, he or she is cognizant of other patients waiting on the line for assistance. A qualitative study in a call centre in Sweden used semi-structured interviews to see how

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telenurses made decisions while using the CDSS under various conditions (Ernesater, Holmstrom & Engstrom, 2009). Interestingly, telenurses reported that when they were tired and under stress (i.e. high call volumes) they relied more heavily on the CDSS (Ernesater et al, 2009). A similar finding was noted in a meta-ethnography by Purc-Stephenson and Thrasher (2010) where situations of long call queues proved to be stressful to telenurses and subsequently, they felt pressured to get through the calls faster and potentially offer a lower standard of care. In this case, it is clear that the telenurse used the CDSS more prescriptively, but the CDSS may also introduce a new dimension to the concept of patient-centered care. As staff cannot keep up with the volumes of individuals who are calling, there may be a potential for a patient-centered approach to be at risk because of the organizational structure. Nauright, Moneyham and Williamson (1999) used a focus group to identify that telenurses were frustrated when they did not feel support to assist callers in a holistic manner. For example, a telenurse assisting caller who clearly demonstrated a need for some health education may not feel supported by management to provide this when there were many other callers waiting in the queue for telenurse advice. In this case, telenurses felt they needed to rush through the call in order to assist the other callers. Telenurses were worried that a caller in the queue could be very ill and thus felt they needed to work more quickly (Nauright et al, 1999). The focus group method used in this study may have been beneficial as it offered a more interactive group approach. Telenurses work in isolation and are only connected to the caller by a

telephone headset and computer; therefore, using focus groups as a methodology may have served as a supportive venue for this information to be shared. In addition, Kitzinger (1995) stated that the use of focus groups was a helpful way of allowing for the

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exploration of knowledge and its underpinnings. In terms of critical thinking and decision making, these three studies provided some context about the CDSS utility under stressful situations. Although only one study was explicit as to how the telenurse used the CDSS (i.e., followed without any deviation), the other two were more focused on managing callers more quickly depending on call volumes (Ernesater et al; Purc-Stephenson and Thrasher; Kitzinger ) Perhaps further probing may have elicited some more detail on the use of the CDSS itself. If we were to compare these situations to those in an acute care hospital, one could analogize that in hospital, a nurse is often busy with his or her patient assignment, especially in light of the aforementioned factors regarding the shift in

hospital patient population. Although a telenurse is only concerned with one caller at a time, the callers in the queue may be construed as those awaiting transfer to the ward from the ER with the exception that the telenurse still has control over when to end the call, albeit he or she may have an internal or organizational pressure to end the call more quickly. A ward nurse usually does not have the option to divert a transfer until he or she is ready as the ER needs to keep up with waiting room demands. As mentioned earlier, there are measurements in place to monitor call length as well as the time it takes to respond to a call. Goodwin (2007) explained that despite the reality that these perceived quality indicators are used to measure telenursing practice, she stated there is no evidence to substantiate this in her literature search. Furthermore, Rutenberg and Oberle (2008) identified that an organization which emphasizes call length as an indicator can cause a form of moral distress when faced with a caller who needs some more support in terms of health education. Reinhardt (2010) echoed this fact in that a supervisor’s oversight of a telenurse’s calls in terms of timing call length was known to increase stress levels to the

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telenurse. She further reported that “setting expectations on call quotas, wait-times and abandonment rates were mentioned as additional stressors” (p. 301). The author’s own telenurse experience suggests that call length is not an appropriate indicator of call quality as this can undermine telenurse practice, and potentially, the judicious use of clinical judgment in making decisions. A telenurse may spend more time with a caller contemplating suicide, and obviously, shortening the call is not safe or ethical practice. Call assessment tools need to measure indicators of patient safety and specific

competencies around the use of making sound clinical nursing decisions.

2.6 Telenurses and Decision Making: Novice to Expert

When a telenurse begins dialogue with a caller, the nursing process begins, just as it

does in any other health care setting. In order to ensure a caller is safe, emergency symptoms are ruled out and subsequently, the telenurse continues with an assessment. The telenurse begins building a mental visual picture of the caller as there is no face to face encounter (Edwards, 1994). Edwards defined picture-building as, “…the process by which nurses attempt to substitute for the physical absence of the client by constructing a mental image of the caller and the situation which she/he is dealing with, p.53). At this point, the telenurse uses standardized protocols within the CDSS to determine a

recommendation. As previously mentioned, it is impossible for the CDSS to provide dispositions to meet each individual caller’s needs; and this is again, why registered nurses (RN’s) provide this service. A telenurse has some degree of latitude and flexibility in using the CDSS. For example, he or she may not agree with a resultant disposition based on some previous knowledge or experience and may choose to ‘upgrade’, or,

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recommend for the caller to seek care sooner. For example, a telenurse may triage a caller using the CDSS with symptoms of an early wound infection, but if the caller suffers from a chronic health condition such as diabetes, there is a higher risk of complications and therefore, the telenurse may choose to recommend a more urgent disposition of care. This practice is more commonly seen in expert telenurses as opposed to novices. This

observation is in alignment with Benner’s research findings in that “the ability of a nurse to focus and act upon contextually bound nuances automatically is a characteristic of expertise” (as cited in Edwards, 1994, p. 718). Dowding et al (2009) performed a

qualitative study of the experience of telenurses’ use of a CDSS and found that telenurses new to the job were more likely to use the system more prescriptively. Through the use of non-participant observation of telenurses as well as interviews, it was noted that

increasing experience and familiarity with the CDSS resulted in a greater likelihood of the application of clinical judgment in decision making (Dowding et al, 2009).

Furthermore, as nursing is such a diverse profession, no telenurse can be knowledgeable about every caller scenario. This study highlighted the fact that the telenurses would use the CDSS like a ‘safety net’ for situations they were not as familiar with (Dowding et al, 2009). Another U.K. qualitative study described the concept of ‘dual triage’ whereby the telenurse independently assessed the caller and then used the CDSS as a complement to the decision-making process (O’Cathain et al, 2003). Interestingly, the telenurses in this study reported that anyone using the CDSS without clinical judgment or critical thinking could be viewed as a ‘monkey’ or a ‘robot’ (O’Cathain et al, 2003). These powerful statements were elicited from interviews performed by the researchers so they were obviously passionate about this. Perhaps some further probing could have offered some

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contextual knowledge or background to this. For example, the author’s own experience as a telenurse illustrated that there have been instances of other telenurses being fearful of losing their job as they could be replaced by non-clinical staff. Perhaps asking some questions to understand the reasons for their statements could have provided some more context.

In using the CDSS, the discussion of upgrading a disposition has been highlighted in terms of how a telenurse uses his or her judgment in making decisions. Interestingly, in a later study from the U.K., there appeared to be a shift in the use of the CDSS because of senior management’s position (Greatbatch et al, 2005). The management maintained that the prescriptive use of the CDSS would limit a telenurse’s independent abilities to use judgment in decision making so as to ensure information is provided in a safe and consistent manner (Greatbatch et al, 2005). It is not explicit in this study as to if the management team had any nursing background which could provide some insight. This use of the CDSS is contrary to the culture of the nursing profession as it does not allow for individualized and patient-centric care. Despite the management’s position, this study revealed that telenurses not only deviated from the use of protocols in terms of upgrading dispositions, but they also found they were downgrading (Greatbatch et al, 2005). So, for example, if a patient was assessed and the recommendation was to seek care within 4 hours, a telenurse might adjust this to a ‘next day’ disposition. According to Koehne (2009), downgrading a disposition is not a recommended practice in telehealth nursing. The standardized protocols in CDSS are written by a variety of health care professionals including nurses and physicians in both general and specialized disciplines. They are also evidence-based and reviewed on a regular basis to ensure accuracy and currency. One

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would hope to assume that the knowledge of these review processes would offer some confidence in that downgrading would not be necessary. Although this practice did occur in this particular study, management made allowances for it by requiring telenurses to document their rationale; however, telenurses did not always comply (Greatbatch et al, 2005). This qualitative study used a wide variety of data collection including audio and video recording, semi structured interviews and non-participant observation (Greatbatch et al, 2005). The use of video recording strengthened this study because they were able to document non-verbal actions such as facial expressions which may be important in understanding how the telenurse used the system (Greatbatch et al, 2005). To provide more data and insight, another valuable methodology might be the use of cued recall, especially in light of the fact that telenurses did not always conform to organizational policies (Greatbatch et al). Using cued recall can offer an immediate method of feedback in reviewing how and why a telenurse used clinical judgment in decision making. This methodology will be discussed in greater detail in chapter three. Also worthy to note is the study provided excerpts of transcriptions for the telenurse-patient interaction, but because there was no legend to address the symbols used to represent verbal intonations, the author had some difficulty in fully understanding the call flow as described within this study. Furthermore, this is a U.K. study whereby the dialect in the English language is different; therefore, the researcher had some challenges in its interpretation.

2.7 Rasmussen’s Decision Ladder

The decision ladder is a framework that was developed by Rasmussen following several studies whereby he used verbal protocols to understand decision making actions

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of experienced workers in thermal power stations (Naikar, 2010). He found that the workers’ use of verbal protocols was associated with a series of reports about their “states of knowledge” in relationship to the power plant that involved their tasks and activities (Naikar, 2010). Rasmussen also noted that there was little or no discussion of any planning or deliberation of options by the workers and thus, it became evident that they had some inherent knowledge of what was occurring because of their experience (Naikar, 2010). If those workers were faced with tasks that were less familiar to them, the verbal protocols demonstrated that they were more analytical in nature and provided more detailed data (Naikar, 2010). It is clear that the decision ladder may serve as a useful framework in novices and experts within a specific work domain. In fact, Rasmussen’s work on human error elicited some interesting adaptation processes in terms of humans interacting with information systems; and this aligns with the concept of novice and expert (Lipshitz, 1992). He found that there were three distinct kinds of behaviour: knowledge-based, rule-based and skill-based (Lipshitz, 1992). These will be discussed further in the use of the decision ladder so as to illustrate how this framework may be useful in many work domains, including telenursing.

Rasmussen (1993) explained that the decision ladder is structured in a linear fashion which includes a situational assessment, planning, development of goals and their priorities. However, as we will see later, this framework is actually designed with heuristic “short-cuts”, whereby the user may be able to move from the left side of the ladder to the right as opposed to following it more prescriptively. The decision ladder is structured so that the left side of the ladder is associated with information processing activities; the top includes evaluation of options; and the right side relates to planning,

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scheduling and implementing (Burns & Vicente, 2001). The ladder includes linkages between the cognitive state, or position of being (i.e. a state of awareness), and the cognitive process (i.e. assessment or planning) (Lintern, 2011). Figure 1 illustrates the ladder as it may apply to telenursing. The rectangles represent information processing activities and the circles illustrate states of knowledge. Jenkins et al (2009) distinguished ‘shunts’, which link an information processing activity to a state of knowledge (rectangle to circle), from ‘leaps’ which may link two states of knowledge without any processing of information (2009). It is not possible; however, to connect two information processes to another as there must be always be a resultant state of knowledge (Jenkins et al, 2009). Rasmussen, Pejtersen and Goodstein (1994) discussed three modes of cognitive control of activities characteristic of novices as opposed to experts. First, knowledge-based control is concerned with a model-knowledge-based approach whereby the individual requires an explicitly formulated goal. This type of information processing is usually concerned with new and unfamiliar situations. In these cases, the use of shortcuts alongside the decision ladder may have very limited utility.

In terms of rule-based control, Lipshitz (1993) described this as behaviour controlled by rules as well as knowledge that can easily be articulated by the decision maker. There may be some level of recognition which may in effect elicit a rule (Lipshitz, 1993). This kind of control might be exemplified when faced with a situation that is familiar, but may not be inherently clear as to how to proceed. Some clarification or further questioning may be required to facilitate decision making and the evidence of heuristics may be present but perhaps not to the same extent. In contrast, the skills-based behaviour is confirmed by the sheer automation of tasks or decision making (Lipshitz, 1993).

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Naikar (2010) proposed that the decision tree framework used in cognitive work analysis may accommodate all three types of behaviour. Knowledge-based behaviour was more evident in workers who are faced with unfamiliar tasks or in novices (Naikar, 2010). In comparison, rule based behaviour demonstrates more utility of heuristic shortcuts, but there will be shifts in the types of behaviour within decision making depending on situational urgency as well as the cohort’s familiarity with a particular scenario, regardless of the profession or domain (Naikar, 2010). There may be some similarities in terms of decision making between areas such as the military and tank warfare applied by Jenkins et al (2009) and health care evidenced by the fact that both domains require a high degree of decision making skills, especially in urgent situations.

2.8 Conclusion

This review of the literature has highlighted some themes pertinent to critical thinking in relationship to how telenurses make decisions using decision support tools. There is a degree of variance in how organizations structure their systems; therefore, there are some challenges in identifying these commonalities. The vast majority of these studies

performed within the context of this subject were carried out in the U.S. and Europe. A particular theme of interest discussed regarding patient outcomes would be extremely useful to study further as the goal of patient safety and satisfaction would be of interest to government, especially if there were any other cost-effective strategies. Furthermore, supporting telenurses with educational opportunities within the realm of critical thinking and decision making may foster a patient centred focus. As there are limited studies done

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Activation of Attention Execution of Acts Alert Procedure Observation, Scanning for Cues Planning of Procedure Focus _Task Identification of System State Definition of Task Evaluate options, Chose Relevant Goal Goals, Constraints Predict Consequences in Terms of Goals and

Constraints Options Goal State Target Look around Seek Information Seek Information Seek Information Look Around Seek Information Seek Information

Figure 1: Rasmussen's Decision Ladder in its Original Form (Rasmussen, 1994).

in Canada, it would be prudent to perform research of this nature in this country to determine any cultural differences in practice.

In terms of frameworks and models, the literature revealed a lack of research studies guiding telenursing practice. As mentioned earlier, there are countless models that were developed by nursing theorists which guide and support nursing practice from a general perspective. The Self-Care model developed by Orem is one that whose theory is based on the premise that nursing is concerned with assisting and facilitating patients to meet their own self-care needs (Loiselle & Profett-McGrath, 2007). This model can certainly

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offer some provisions for an overarching foundation for empowering callers. It is not as explicit in understanding the cognitive processes within decision making, especially in the presence of HIS. Greenberg (2009) proposed a model for telenursing that identified information gathering, cognitive processing and outputs. Although she did propose it do be an iterative process, moving back and forth between these stages, it did not

specifically address heuristic shortcuts that telenurses use when faced with situations which may warrant urgent symptoms. Leprohon and Patel’s (1994) study on decision making strategies actually identified that nurses used heuristic shortcuts in patients with serious and life-threatening symptoms when using a CDSS. Furthermore, the nurses’ use of these shortcuts proved to provide highly accurate recommendations (Leprohon & Patel, 1994). The potential for a model to address a collaboration of these elements of telenursing may have some exciting implications for supporting, enhancing and appreciating this extraordinary area of nursing practice. It is clear that researching telenurse’s experience of using CDSS in terms of decision making and the application of Rasmussen’s decision ladder as a framework can offer some valuable insights for the future of telenursing.

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CHAPTER 3: RESEARCH APPROACH

3.1 Research Methodologies

A qualitative approach was chosen to perform this research as the researcher was concerned with exploring the experience of decision making in when a telenurse used a CDSS. Furthermore, as the researcher was exploring the underlying cognitive processes of decision making, it was important that the various concepts that underpin these processes emerged as well as their linkages. As the researcher was concerned with validating Rasmussen’s Decision Ladder as a framework to support telenursing, it was important to use a methodology in which the concepts were aligned. The decision ladder included some generic coding within the stages of information processing and resultant states of knowledge; therefore, a model based approach to coding the data was used. Table 1 illustrates the potential variations on the original terminology used within Rasmussen’s Decision Ladder as it might apply to telenursing. These terms were based upon the experience of a telenurse’s workflow in how calls were managed from the time that a caller was assisted with their health issue. Borycki, Lemieux-Charles, Nagle and Eysenbach (2009) used this approach in evaluating how novice nurses seek information when working in environments that use hybrid systems (i.e. paper and electronic based environments). This approach was useful in demonstrating information seeking activities in hybrid environments with the use of an existing model (Borycki et al 2009). The definitions as related to the decision ladder were in alignment with the information seeking tactics described in this particular paper (Borycki et al, 2009). As decision

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making is clearly associated with information processing, testing Rasmussen’s Decision Ladder using this approach was an appropriate choice.

3.2 Participants

In the attempt to understanding the experience of a telenurse’s use of the CDSS a sample of telenurses was clearly the most appropriate choice. As participants, telenurses were able to provide an insider perspective of the true realities in how they reach

decisions. In terms of sampling, the focus in this qualitative research was on description and exploration; therefore, large numbers were not required for generalization across the population as is in the case of quantitative methods. Eight telenurses participated in the study and in fact, this is the typical number noted in research in order to reach saturation. Similar telenurse related studies using a qualitative approach used samples of anywhere between five to ten telenurses resulting in rich data and saturation (Edwards, 1998; Greenberg, 2009). Furthermore, a convenience method of recruiting telenurses was used for selection as the operational requirements in terms of service levels and callers waiting would affect the availability of telenurses.

3.3 Inclusion Criteria

One of the first criteria in participant selection was the length of employment at the telenurse call centre chosen for this study (Centre A), as this helped to distinguish the novice nurse from the expert. Dowding et al (2009) performed a qualitative study of the experience of nurses’ use of a CDSS and found that telenurses new to the job were more likely to use the tool more prescriptively. As they became more familiar with the tool,

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they were more likely to deviate by ‘upgrading’. Call Centre A’s last session of

recruitment was very recent; therefore, there might have been some variety in the levels of competency along the novice to expert continuum. This might have been helpful in identifying some key factors that distinguish the novice from the expert telenurse. However, there were no novice telenurses that decided to participate. Additionally, the actual criteria for employment as a telenurse at Call Centre A requires that the nurse have at least three to five years of experience in an acute care, public health or emergency room setting. In terms of computer and keyboarding skills, a telenurse needs to type at least 30 words per minute as well as some basic windows knowledge. In fact, the average telenurse at Centre A has an average of approximately sixteen years of experience.

3.4 Recruitment

As most of the telenursing staff met the inclusion criteria, the researcher chose

participants based on operational requirements and scheduling as well as their willingness to participate. The author sent an email notification outlining the study. In addition, the email included a section on a request for telenurses who would be interested to reply. As emailed responses came in, their years/months of telenurse experience were reviewed (this was asked in the email) and a purposive sample of novice to expert telenurses (approximately 6-8) was selected. The purpose of this was to be able to understand the factors involved in decision making between novice and expert telenurses as this has been highlighted as a major influence in the literature review. In this study, none of the novice telenurses responded and so this was not tested. At the time of the study, the telenurses who were selected were asked to sign a consent form. They were then

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debriefed on the data collection process as well as provided with a questionnaire (Appendix A) to collect demographic information on the telenurse’s experience.

3.5 Research Setting

It was most logical as well as practical to perform this research in the most

naturalistic setting possible, which was the telehealth nursing call centre (Centre A). The researcher was aware of the fact that research studies in health informatics have

previously been conducted at the Centre A; therefore, this precedence provided some influence on permission to move forward with this research. Permission was granted by the organizational executive director to perform this research. Hall, Kushniruk and Borycki (2011) performed a study that utilized usability engineering methodologies to evaluate the HIS at Centre A. This study was based more upon user interface design and features. In fact, one of its recommendations was to perform further research in

determining the potential to which software usability may influence telenurse job

satisfaction (Hall et al, 2011). This particular study used a usability methodology entitled cognitive task screen turn analysis (CTSTA) within the clinical simulations. Hall et al (2011) explained this as “a method we have developed where a screen-turn is defined as a user initiated request of the system to perform an action resulting in the display of a new screen of information”, (p. 4). This research did not formally address job satisfaction explicitly, but certainly there were some areas in which telenurses expressed emotions during the interview.

A telenurse workstation within the call centre was used for this study in order to maintain a naturalistic setting. Figure 2 illustrates the workstation design in terms of how a telenurse interacts with the telephony and the HIS. The location of the workstation in

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relationship to the call centre was arranged so that there were no disruptions or distractions to other telenurses on live calls.

bookshelf for print resources video camera Participant dual monitors screen recording software

Figure 2: Telenurse Workstation Design for Clinical Simulation.

3.6 Procedure

Borycki, Kushniruk, Anderson, J. and Anderson M. (2010) discussed the use of clinical simulation as a methodology used by health professionals to enhance and improve clinical knowledge as well as evaluating the use of HIS. As previously mentioned, Hall et al’s (2011) research was performed using a simulated call very effectively in evaluating the usability of the EMR and the CDSS. The use of clinical

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simulation, therefore, was an excellent approach to capturing the true essence of critical thinking and decision making in order to test Rasmussen’s Decision Ladder as a

framework in telenursing. Furthermore, the literature review only identified two studies where clinical simulation was used in some capacity (Edwards, 1994; Hall, Kushniruk & Borycki, 2011). The remaining methodologies used included surveys and focus groups and thus, utilizing clinical simulation, particularly where a telenurse used a CDSS, had some new and exciting implications. Two simulated call scenarios were tested. One involved a caller with urgent symptoms of a heart attack, and the other consisted of a new postpartum mom with symptoms of a potential mastitis and her newborn baby. These were chosen with the premise that they would both follow a different pathway along the decision ladder (i.e., one demonstrated urgency along with the use of heuristic shortcuts while the other was more complex and used in a more linear fashion). In essence, these two scenarios would follow a different pathway in terms of workflow. These two scenarios were validated as examples of common calls at Centre A by the Quality

Management nurses and the Clinical Educators. As these calls were simulated within the telenurse call centre, there was no impact to patient privacy and therefore, no special permissions were required. These calls were also audio recorded by specialized telephony. The computer screens were recorded by Camtasia© software so as to offer further data in how the telenurse used the CDSS (Hall et al, 2011). Upon completion of the call, the researcher played back the audio and computer screen recordings for the telenurse and she was asked to comment on her decision making experiences. These verbalizations were also audio recorded for further analysis. After the call was played back, the researcher asked open ended questions in the form of semi-structured

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interviews to clarify these verbalizations (see Appendix A). This cued recall approach served to extract data in truly understanding a telenurse’s cognitive processes. Cued recall was particularly useful in terms of reviewing playback and identifying a telenurse’s thoughts while using the CDSS.

3.7 Data Analysis

Transcription and analysis took place as soon as the collected data was reviewed in order to ensure that accuracy was preserved. In addition, constant comparison of the data occurred so as to identify any similarities or differences (Jackson & Verberg, 2007). This iterative process ensured that every piece of data was examined and re-examined for any potential emerging themes as well as some validation that saturation has been reached. As the goal of this cyclical process was to makes some sense of the data, the researcher was fully immersed in the analysis.

Content analysis was used as a method of systematically deconstructing the data. Priest, Roberts and Woods (2003) described this particular method as being specifically reliable in coding decisions as there was an opportunity for assessing data integrity and stability. As the researcher used a model-based coding approach, the analyzed data was compared to the terminology within Table 1. New descriptors of the coding emerged; and these were added to the list of terminology. In addition, the behaviours that were

influenced by factors previously mentioned (i.e. novice to expert, stress and fatigue) were analyzed in how these fit in with telenursing. Table 2 provides an overview of how these behaviours may be construed based on the literature.

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Once all of the data was analyzed, the researcher mapped out the various trajectories of call-taking by telenurses using Rasmussen’s Decision Ladder in order to understand its utility as a framework in telenursing. In doing so, detail was provided with respect to the Decision Ladder: Coding Terms

Nursing Process Phase Rasmussen’s Decision Ladder (Naikar, 2010) Definition of decision ladder terms Mapped to Telehealth: States of Knowledge (Circles) Mapped to Telehealth Information Processing (rectangular)

Assessment Activation Detect need for action

Anticipating a new patient encounter

Alert What needs

attention?

Alert Data

Actual State New Caller on the line Observe information and data, scanning for cues Active and Passive information seeking techniques (Borycki et al, 2009) Observe data Listen to caller Anticipate Identify options Perception

Rule out 911 symptoms to ensure caller safety Information What is the

current state

Knowledge of caller’s health status

Diagnose State Active and Passive information seeking techniques (Borycki et al, 2009) Review potential nursing diagnoses

System State Triage options

Predict Consequences Predict consequences Plan comprehension Formulate plan Options Information Evaluate Performance

Evaluate triage options Overarching goal Goal of a safe caller outcome Chosen Goal

Sit

uational A

nal

y

sis

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varying behaviours in how heuristic shortcuts were (or were not) used in telenursing. There were many different scenarios based on the demographic of the telenurse and experiential background; and these were outlined and mapped in detail in order to fully substantiate this potential framework for telenursing.

Planning Predict

Consequences

Target state Predict consequences Plan comprehension Formulate plan

Target State Safe care for caller

Implement ation

Definition of task

Triage with CDSS Decision Ladder: Coding Terms

Nursing Process Phase Rasmussen’s Decision Ladder (Naikar, 2010) Definition of decision ladder terms Mapped to Telehealth: States of Knowledge (Circles) Mapped to Telehealth Information Processing (rectangular) Task Recommended disposition obtained Planning of Procedure

Planning of caller care Execute

Implement Evaluation Procedure Active and

Passive information seeking techniques (Borycki et al, 2009) Caller verified understanding Understand consequences if recommendations not followed Tasks Resources

Execute End Call and document

in client record Table 1 Mapping of Decision Ladder Concepts to Codes for Analyzing Telenursing Decision Processes.

Behaviours Novice Telenurse Expert Telenurse Unfamiliar Scenario Stress/ Fatigue Knowledge

Based Behaviour

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Table 2 Potential Manifestations of the Various Behaviours as Related to Telenursing.

3.8 Ethics Approval

In August 2013, an ethics review application was submitted to the University of Victoria Human Research Ethics Board. Ethics approval was provided on October 2013. Data collection activities started following this approval. See Appendix 4 for

documentation.

3.9 Conclusion

Telehealth nursing has been recognized as an economically effective platform for the delivery of health care. Research has been done in countries such as the U.K. and Sweden in order to identify how telenurses make decisions using HIS. This research provided some understanding regarding a telenurse’s level of critical thinking. This knowledge is important to supporting telenurses with educational opportunities within the realm of critical thinking and decision making. In addition, this knowledge has the potential to foster a patient centred focus as well as facilitating safe and quality patient outcomes. Because there are limited studies conducted in Canada, it was important for this research to be implemented as it would contribute to ongoing quality improvement to nursing practice as well as HIS including CDSS. Furthermore, no such study has been performed Rule Based Behaviour (shortcuts) x Skills Based Behaviour (automatic) x

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at Call Centre A (or any other call centre known to the researcher); therefore, the results may have some interesting implications.

Models and frameworks are fundamental in providing guidance as well as support in the ongoing quality of professions, and telenursing is no different. There are many possible propositions that could ensue from the development of this framework. First, is the creation of partnerships between other telenurse call centres. In fact, there is no established collaborative network that the researcher is aware of across Canada. Next, there is potential for this research to spark interest in this topic in other Canadian telenurse settings whereby practices could be shared such as understanding some of the lessons learned in telenurse related projects. Certainly, this is dependent on the level of proprietary knowledge a particular organization maintains. Finally, this work could serve to offer some foundational knowledge in forthcoming business opportunities, such as in chronic disease management and other specialized telenurse related services. This research has outlined a number of potential impacts that may bridge some of the gaps to telehealth care delivery provincially, if not nationally or globally.

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CHAPTER 4: STUDY FINDINGS

4.1 Introduction

Based on the data collection and analysis, this section provides an overview of the observations and study findings from the clinical simulations performed at Call Center A as well as the post cued call interview questions. These include findings about the

characteristics of the participants and observations made about decision making processes as mapped to Rasmussen’s Decision Ladder. Furthermore, the factors that influenced how participants made decisions as well as the use of short cuts within the decision ladder were identified. For the purposes of this section, the terms “telenurse” and “participant” were used interchangeably.

4.2 Demographic Characteristic of Participants

It is important to gather information about the demographic characteristics of the telenurse to understand how knowledge and experience as well as other potential factors influence decision making. Nurses come from various fields of work (i.e. acute care, community care, and geriatrics, to name a small number of specialty areas in nursing). Furthermore, the full time equivalent (FTE) of a telenurse’s amount of time worked may also play a role in understanding decision making in terms of the relationship between how many hours the telenurse works (i.e. full time versus part time) simply because he or she has logged more hours and thus has more experience. In addition to this, working in other organizations as well as in a telenursing organization concurrently can impact decision making. For example, if a RN works as a telenurse in Call Centre A and part